| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,581 |
1,580 |
$84K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
390 |
358 |
$57K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
408 |
381 |
$53K |
| D0274 |
Bitewings - four radiographic images |
1,489 |
1,489 |
$40K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
53 |
50 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,221 |
1,220 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
1,991 |
1,972 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
773 |
773 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,942 |
1,936 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
202 |
195 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
752 |
738 |
$9K |
| D2954 |
|
19 |
19 |
$3K |
| D1120 |
Prophylaxis - child |
110 |
110 |
$3K |
| D0330 |
Panoramic radiographic image |
90 |
89 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
163 |
158 |
$2K |
| D1206 |
Topical application of fluoride varnish |
57 |
57 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
53 |
53 |
$742.00 |